MetisMD Privacy Practices

 

HIPAA AND OUR PATIENTS

• The Health Insurance Portability and Accounting Act (“HIPAA”) Privacy Rule controls the use and disclosure of what is known as Protected Health Information (“PHI”). Implementation of and compliance with this rule is not optional for our practice. We are required to give you the attached information.

• Please read and familiarize yourself with the attached material. Feel free to print out a copy for your records.

• Please indicate your receipt of this Notice below. It will be a permanent part of your medical record.

• If you are a parent or legal guardian of a patient, we will need a consent form signed by you for the patient.

Use and Disclosure of Protected Health Information

MetisMD, LLC may use and disclose Protected Health Information (“PHI”) about you to carry out Treatment, Payment and Healthcare Operations (“TPO”). Please refer to our Notice of Privacy Practices (“Notice”) for a more complete description of such uses and disclosures. You have the right to review our Notice prior to accepting this Notice below. We reserve the right to revise our Notice at any time. Any such revised Notice will be provided to you.

MetisMD, LLC may mail to your residence any items that assist us in carrying out TPO, such as letters and patient statements.

By indicating your acceptance of this Notice, you are consenting to our use and disclosure of your PHI to carry out treatment, payment and healthcare operations. Your agreement to this Notice may be revoked in writing except to the extent that we may have already made disclosures in reliance upon your prior acceptance.

HIPAA Notice of Privacy Practices (“Notice”)

Effective Date: January 1, 2011

This Notice describes how information about you may be used and disclosed and how you can get access to this information. Please review carefully.

If you have any questions about this Notice please contact our privacy officer, Gregory Goldstein, M.D. at 800-695-8191 or 415 North LaSalle St. Suite 502 Chicago, IL 60654. This Notice describes how MetisMD, LLC and our health care professionals, employees, trainees and staff may use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are described in this Notice. We understand that medical information about you and your health is

personal and we are committed to protecting medical information about you. This Notice applies to all records of your care generated by this practice.

This Notice also describes your rights to access and control your medical information. This information about you includes demographic information, that may identify you and that relates to your past, present and future physical or mental health or condition and related health care services. Typically your medical information will include symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment.

We are required by law to protect the privacy of your medical information and to follow the terms of this Notice. We may change the terms of this Notice, at any time. The new Notice will then be effective for all medical information that we maintain at that time. We will provide you with any revised Notice if you request a revised copy be sent to you in the mail or provided to you at your next service.

I. Uses and Disclosures of Protected Health Information.

MetisMD, LLC will ask you to indicate your acceptance of this Notice and once you have accepted this Notice, we will use or disclose your medical information as described in this Notice. Your medical information may be used and disclosed by MetisMD, LLC and others that are involved in your care and treatment for the purpose of providing health care services to you. Your medical information may also be used and disclosed to pay your health care bills and to support the operation of MetisMD, LLC.

The following are examples of different ways we use and disclose medical information. These are examples only.

(a) Treatment:

We may use and disclose medical information about you to provide, coordinate or manage your medical treatment or any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your medical information. For example, we could disclose your medical information to a residential care facility that provides care to you. We may also disclose medical information to other physicians who may be treating you, such as your primary care physician, to ensure that the physician has the necessary information to diagnose or treat you.

(b) Payment:

We may use and disclose medical information about you to obtain payment for the treatment and services you receive from us. For example, we may need to give Medicare, Medicaid or other health insurance plan you maintain information about your treatment plan so that they can make a determination of eligibility or to obtain prior approval for planned treatment.

(c) Healthcare Operations:

We may use or disclose medical information about you in order to support the business activities of MetisMD, LLC. These activities include, but are not limited to, reviewing our treatment of you, employee performance reviews, training of medical students, licensing, marketing and fund raising activities and conducting or arranging for other business activities.

We may share your medical information with third party “business associates” that perform activities such as billing or transcription. Whenever an arrangement between our office and a business associate involves the use or disclosure of your medical information, we will have a written contract that contains terms that asks the “business associate” to protect the privacy of your medical information.

We may use or disclose your medical information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your medical information for other marketing activities. For example, your name and address may be used to send you a newsletter about MetisMD, LLC and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our privacy contact to request that these materials not be sent to you.

II. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object.

We may use and disclose your medical information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your medical information. If you are not present or able to agree or object to the use or disclosure of the medical information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the medical information that is relevant to your health care will be disclosed.

(a) Others Involved in Your Healthcare:

Unless you object, we may disclose to a member of your family, a relative, guardian or close friend your medical information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information if we determine that it is in your best interest based on our professional judgment. We may use or disclose medical information to notify or assist in notifying a family member or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your medical information to an entity assisting in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

(b) Emergencies:

We may use or disclose your medical information for emergency treatment. If this happens, MetisMD, LLC shall try to obtain your consent as soon as reasonable after the delivery of treatment. If the practice is required by law to treat you and has attempted to obtain your consent but is unable to obtain your consent, the practice may still use or disclose your medical information to treat you.

(c) Communication Barriers:

We may use and disclose your medical information if the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and in our professional judgment you intended to consent to use to use or disclosure under the circumstances.

III. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object.

We may use or disclose your medical information in the following situations without your consent or authorization. These situations include:

(a) Required By Law:

We may use or disclose your medical information when federal, state or local law requires disclosure. You will be notified of any such uses or disclosure.

(b) Public Health:

We may disclose your medical information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. This disclosure will be made for the purpose of controlling disease, injury or disability.

(c) Communicable Diseases:

We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

(d) Health Oversight:

We may disclose medical information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. These activities are necessary for the government agencies to oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

(e) Abuse or Neglect:

We may disclose your medical information to a governmental entity authorized to receive such information if we believe that you have been a victim of abuse, neglect or domestic violence as is consistent with the requirements of applicable federal and state laws.

(f) Food and Drug Administration:

We may disclose your medical information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

(g) Legal Proceedings:

We may disclose medical information in the course of any judicial or administrative proceeding, when required by a court order or administrative tribunal, and in certain conditions in response to a subpoena, discovery request or other lawful process.

(h) Law Enforcement:

We may disclose medical information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include: (i) in response to a court order, subpoena, warrant, summons or otherwise required by law; (ii) to identify or locate a suspect, fugitive, material witness or missing person; (iii) pertaining to victims of a crime; (iv) suspicion that death has occurred as a result of criminal conduct; (v) in the event that a crime occurs on the premises of the practice; and (vi) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

(i) Coroners, Funeral Directors, and Organ Donors:

We may disclose medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose medical information to funeral directors as necessary to carry out their duties.

(j) Research:

We may disclose your medical information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your medical information has approved their research.

(k) Criminal Activity:

Consistent with applicable federal and state laws, we may disclose your medical information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose medical information if it is necessary for law enforcement authorities to identify or apprehend an individual.

(l) Organ and Tissue Donation:

If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

(m) Required Uses and Disclosures:

Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 etc. seq.

IV. The following is a statement of your rights with respect to your medical information and a brief description of how you may exercise these rights.

(a) You have the right to inspect and copy your medical information.

This means you may inspect and obtain a copy of medical information about you that has originated in our practice. We may charge you a reasonable fee for copying and mailing records.

After you have made a written request, our privacy officer, we will have thirty (30) days to satisfy your request. If we deny your request to inspect or copy your medical information, we will provide you with a written explanation of the denial.

(b) You have the right to request a restriction of your medical information.

You may ask us not to use or disclose part of your medical information for the purposes of treatment, payment or healthcare operations. You may also request that part of your medical information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. You must state in writing the specific restriction requested and to whom you want the restriction to apply.

(c) MetisMD, LLC is not required to agree to your request.

If we believe it is in your best interest to permit use and disclosure of your medical information, your medical information will not be restricted. If we do agree to the requested restriction, we may not use or disclose your medical information in violation of that restriction unless it is needed to provide emergency treatment. Your written request must be specific as to what information you want to limit and to whom you want the limits to apply. The request should be sent to our privacy contact.

(d) You have the right to request to receive confidential communications from us at a location other than your primary address.

We will try to accommodate reasonable requests. Please make this request in writing to the privacy officer.

(e) You may have the right to have MetisMD, LLC amend your medical information.

If you feel that medical information we have about you is incorrect or incomplete, you may request we amend the information. If you wish to request an amendment to your medical information, please contact our privacy contact in writing to request our form Request to Amend Health Information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us.

(f) You have the right to receive an accounting of disclosures we have made, if any, of your medical information.

This applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, family members or friends involved in your care, or for notification purposes. To receive information regarding disclosures made for a specific time period, please submit your request in writing to our privacy contact. We will notify you in writing of the cost involved in preparing this list.

(g) Uses and Disclosures of Protected Health Information Based upon Your Written Authorization.

Other uses and disclosures of your medical information not covered by this notice or required by law will be made only with your written authorization. You may revoke this authorization at any time, except to the extent that our practice has taken an action in reliance on the use or disclosure indicated in the prior authorization.

(h) Complaints:

You may complain to us or to the Secretary Of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer. We will not retaliate against you for filing a complaint.

Please indicate your acceptance of this Notice below. MetisMD, LLC cannot provide services to you unless such acceptance is provided.